Inside the wait for Medicaid expansion in North Carolina, one of 12 states spurning a federally-funded healthcare boost for low-income people.
Chrissy Burk looks up home remedies when she’s sick, knowing a doctor visit is usually too costly for this single mom of two.
So when a $150 price tag recently made a needed prescription a luxury item, she left it unfilled.
“I really could have benefited from the medicine from the pharmacy, I just couldn’t afford it at that time, because I have no insurance,” said Burk, who lives in Cumberland County. “My checks barely pay my bills. I have to pick if I want to pay my light bill, my cell phone bill, put gas in my car, the cable, or food.”
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Burk is one of the estimated 400,000 to 600,000 North Carolinians without health care, most caught in what’s referred to as the Medicaid coverage gap. North Carolina is one of 12 states, largely in the South, that have spent the years since 2014 turning down offers from the federal government to pay for nearly all the cost of expanding the state’s Medicaid safety net program to people like Burk.
But that could still change, with at least some chance Medicaid expansion could emerge from the state budget process and two federal proposals in Congress bypassing state lawmakers completely.
Burk works full time for a janitorial services company, but gets no health insurance through her job. She doesn’t make enough for subsidies on the federal health insurance marketplace at HealthCare.gov to kick in.
Medicaid is traditionally for low-income children and some of their family members, seniors and people with disabilities. But the Affordable Care Act allowed states to add poor adults otherwise unable to afford health insurance. Most states have done this and seen quantifiable benefits.
Healthier babies are being born in Medicaid expansion states, cancer is getting detected earlier, and home ownership is going up while bankruptcies go down because people aren’t saddled with as much medical debt. Hospitals in rural areas are also more likely to stay open in these Medicaid expansion states.
Meanwhile, things aren’t going as well in North Carolina. A thousand people die each year due to the state’s decision to not expand Medicaid, a 2020 report from the NC Poverty Research Fund found. Hospitals in more rural areas operate with small margins, and end up serving a larger share of uninsured people because of the struggling economies in their areas. That puts them at risk of closing. The state has had seven hospitals close their doors since 2013, according to data from the Sheps Center at the University of North Carolina at Chapel Hill.
“The opportunity for us to expand Medicaid here in North Carolina can literally save lives,” state Sen. Jay Chaudhuri, a Democrat from Wake County, said in Raleigh last week.
People in North Carolina’s coverage gap are often working retail or restaurant jobs, taking care of babies and toddlers at daycare centers, or doing custodial work like Burke. All jobs that have people out in the world, interacting with others in the midst of the worst public health crisis in more than a century.
That scares Burk, who was robbed at gunpoint at a past retail job at a dollar store. She wasn’t able to afford counseling to deal with the resulting trauma.
“It’s a risk leaving the house every day and if we don’t have insurance, it’s a greater risk,” Burk said. “Because then we’re going to the hospital, we’re getting told we’re sick, but then we can’t afford the medicine. And then while we’re there, you’re going to hit us with a big bill anyway.”
Federal Solution for NC?
There may be hope, however, for those going without health insurance in North Carolina. At least two proposals in Congress being pushed by Democrats would circumvent the state-level officials standing in the way.
And here in North Carolina, lawmakers at the state level and Gov. Roy Cooper are pushing during ongoing budget negotiations to finally clear Medicaid expansion.
US Rep. Kathy Manning, a freshman Democrat from Greensboro, is one of the sponsors of the Medicaid Saves Lives Act which, if passed, would let people opt into the program if they live in non-expansion states like North Carolina. Another bill would allow counties or cities to opt into Medicaid expansion.
“This is a creative and realistic solution to the problem that’s created by our state legislature’s continued refusal to expand Medicaid in our state,” Manning said in July during a virtual discussion of Medicaid expansion. “We’ve seen what that lack of access to health care has meant in terms of people getting sicker from COVID and, frankly, dying from COVID, and we cannot tolerate that anymore.”
GOP Resistance in NC’s Legislature
Three out of four North Carolina voters are in favor of Medicaid expansion, according to a survey conducted last year by Care4Carolina, a coalition that’s pushing for expanded Medicaid.
But the politicians North Carolina elected to the state legislature, where the decision to expand Medicaid needs to be made, aren’t in step with voters’ desires.
Republican leaders who control both the House and Senate say that the state could eventually be on the hook for some of the cost of coverage, although the federal government has paid all or most of the bill since the Affordable Care Act expanded Medicaid in 2014. GOP lawmakers in North Carolina have also said that they fear the state’s existing health care networks couldn’t handle the influx of newly-insured people.
The issue hasn’t been as bitterly partisan in other states. Conservative-leaning states like Oklahoma and Utah expanded their Medicaid programs after voters in the states opted for it.
And expanding Medicaid right now would have an even bigger payout for North Carolina. The American Rescue Plan, the COVID-19 relief package backed by the Biden administration, would send North Carolina an additional $1.7 billion to pay for the existing Medicaid program if the state says “yes” to expansion.
There’s some renewed hope that Republican lawmakers in North Carolina could begrudgingly agree to allow Medicaid expansion as negotiations over the state budget continue. The state is awaiting a conference report — a compromise budget — from the House and Senate.
Medicaid expansion “may be included in the conference report,” state Sen. Gladys Robinson, a Greensboro Democrat, said this summer. “Hopefully we’ll have something coming through that or afterwards.”
Cooper vetoed the budget two years ago when it didn’t include Medicaid expansion, and could again use the threat of a veto. When asked about Cooper’s intentions this year, his office reiterated that getting North Carolinians covered was a top goal.
“In discussions with legislative leaders, the Governor has been clear that his priorities – including Medicaid expansion, teacher pay, and funding a sound basic education – must be on the table for negotiation,” Cooper spokesperson Mary Scott Winstead said in a statement to Cardinal & Pine. “A compromise will need to reflect both his priorities and those of legislators.”
A wide coalition of people from around the state are in favor of Medicaid expansion, including those that run hospitals or who live in more conservative areas.
“We’ve got people here that literally can’t afford to be sick; they’re living from paycheck to paycheck,” Dale Wiggins, the Republican chair of the Graham County Board of Commissioner, told NC Health News in 2019. “If a parent gets sick, loses a couple of weeks work, you know, they could potentially lose a car and lose a home.”
Burk, the Cumberland County mom, knows that struggle.
She wishes politicians opposed to Medicaid expansion would realize, “‘Okay, these people need help. How can we help them in their situation get the help they need, to help their families survive through these tough times?’”
Until then, she’s left hoping she doesn’t get sick.